Download Behavioral approaches to the treatment of obesity

15
Behavioral approaches to the treatment
of obesity
Meghan L. Butryn, Vicki L. Clark, and Maria C. Coletta
Learning Objectives
The reader will be able to:
• Name the key components of behavioral treatment for obesity.
• Describe the typical pattern of weight changes up to a year following treatment.
• Describe what information is used in treatment sessions.
• Name and explain some of the techniques used during treatment.
• List several diet types that can be used in conjunction with behavioral therapy.
• Name one approach for monitoring and increasing physical activity during therapy.
Introduction
Whether for weight loss or to prevent weight gain or
regain, behavioral treatment is a first-line approach to
obesity intervention. This chapter begins by reviewing
data on the effectiveness of behavioral treatment, documenting that short-term results are impressive and
that long-term weight loss maintenance remains challenging. Next, the principles and structure of behavioral
treatment are reviewed in detail. Several key components
are described: self-monitoring of eating, physical
activity, and weight; stimulus control; problem-solving;
cognitive restructuring; and relapse prevention. Behavio­
ral treatment can be conducted with various types of
dietary intervention. Several dietary options are des­
cribed and evaluated, including use of very-low-calorie
diets, meal replacements, portion-controlled diets,
low-carbohydrate diets, and low energy-density diets.
The role of physical activity is examined, as are several
methods of promoting physical activity within behavioral treatment. Finally, additional methods of improving
the long-term effectiveness of behavioral treatment are
considered.
The promise and challenge of behavioral
treatment: short- and long-term effectiveness
The National Heart, Lung, and Blood Institute recommends that a program of diet, exercise, and behavior
therapy be provided as the first line of treatment for
obesity (1). As shown in Table 15-1, patients who received
behavioral treatment lost an average of approximately
10% of their initial weight (on average, the equivalent of
10 kg) in an average of 30 weeks of treatment. In the
1990s, treatment length increased substantially, which
was associated with a corresponding increase in weight
loss. Participants typically lost 0.4–0.5 kg per week (2)
and reached their peak weight loss by six months (3).
The rate of discontinuing treatment prematurely was
approximately 20% (Table 15-1). Many studies have
conducted follow-up evaluations of adults who participated in behavioral treatment programs. On average,
30–35% of weight loss was regained in the year following
treatment (4). By 45 years after treatment, patients maintained an average weight loss of approximately 1–3 kg,
and many patients regained all of the weight that they
lost (5–6).
Textbook of Obesity: Biological, Psychological and Cultural Influences, First Edition.
Edited by Sharon R. Akabas, Sally Ann Lederman, Barbara J. Moore.
© 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
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Table 15-1 Summary of Effectiveness of Behavior Therapy for Obesity
Characteristics
1974
1985–87
1991–95
1996–2002
No. of studies
Mean sample size
Initial weight, kg
Length of treatment, wk
Weight loss, kg
Loss per week, kg
Attrition, %
Length of follow-up, wk
Weight loss at follow-up, kg
15
53.1
73.4
8.4
3.8
0.5
11.4
15.1
4.0
13
71.6
87.2
15.6
8.4
0.5
13.8
48.3
5.3
5
30.2
94.9
22.2
8.5
0.4
18.5
47.7
5.9
9
28.0
92.2
31.4
10.7
0.4
21.2
41.8
7.2
All data are from randomized controlled trials of behavioral treatment published
from 1974 to 2002 in select journals. All values, except for number of studies,
are weighted means; thus, studies with larger sample sizes had a greater
impact on mean values than did studies with smaller sample sizes. Table
reprinted from reference (2), which was adapted and updated from ref (133).
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These results are disappointing for most patients.
However, several novel interventions have facilitated
greater long-term success, such as those that used a
model of continued care after initial weight loss. Recently
published data from the Look AHEAD study found that
after four years of continued treatment, participants
maintained a weight loss of 4.7% of initial weight (7).
Research, such as that from the Diabetes Prevention
Program, also has demonstrated that relatively modest
weight losses produce meaningful health benefits (8). In
that study, 3,200 overweight or obese participants with
impaired glucose tolerance were enrolled. Participants
who received behavioral treatment achieved a weight
loss of, on average, 7 kg at the end of one year, and they
regained approximately one-third of their weight in the
2–3 years after that. Even in the context of weight regain,
these participants reduced their risk of developing type
2 diabetes by 58% compared to participants treated with
placebo.
Although most studies find that the size of
sustained weight losses is small, there is a subgroup of
participants who maintain much larger weight losses.
In general, about 20% of participants maintain a
weight loss of at least 10% one year after treatment
ends (9). Research is being conducted to learn about
individual differences that are associated with these
remarkable cases of successful long-term weight con­
trol. The final section of this chapter provides more
infor­mation on the important topic of weight loss
maintenance.
Principles and structure of behavioral treatment
The first application of behavioral principles to the treatment of obesity, described in 1967, was designed to
target maladaptive eating behaviors which were believed
to be the primary cause of obesity (10). Today, the influence of genetic and metabolic factors on body weight is
well known (see Chapter 5). These biological factors predispose certain individuals to obesity, particularly in
combination with environmental influences that encourage overconsumption of highly palatable, high-calorie
foods and discourage physical activity (see Chapter 6)
(11). Modern behavior therapy recognizes these influences on body weight while maintaining that modifications of eating and activity behaviors can help obese
individuals achieve a healthier weight. Therefore, behavioral treatment applies principles of learning theories,
such as classical conditioning and operant conditioning,
to the regulation of body weight in order to help obese
individuals make lifelong changes to their eating and
activity habits.
Principles of behavioral treatment
Classical conditioning is a form of associative learning
in which two stimuli become linked together if they are
paired repeatedly. The association becomes stronger the
more frequently they are paired until the presence of one
stimulus automatically triggers the other. For example, a
person who frequently eats while watching television
might eventually experience an urge to eat whenever she
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Behavioral approaches 255
turns on the television. A goal of behavior therapy is to
identify and extinguish these associations by “unpairing”
them. Restricting eating to certain places (e.g., the
kitchen table) is often recommended in order to eliminate such an association between watching television
and eating.
Behavior therapy uses principles of operant conditioning to promote behavior change by manipulating the
consequences of eating and activity. Behaviors that are
rewarded (i.e., reinforced) are more likely to be repeated.
A participant who loses weight following a week of
eating in accordance with his calorie goal will be more
likely to continue to adhere to his calorie goal in the
future. In this instance, weight loss is the reward that
reinforces the desired behavior. On the other hand,
behaviors that are followed by negative consequences are
less likely to be repeated. For example, an individual who
increases her activity level by 200 minutes in one week
may feel exhausted and fatigued. As a result, she may feel
discouraged from continuing her exercise program. If
she began with a more modest exercise regimen (e.g., 10
minutes of exercise, 5 days per week) and gradually
increased her activity level, she would be less likely to
experience negative consequences of her behavior.
As described in the following section, each treatment
session begins with a private weigh-in. The weigh-in is
designed, in part, to provide feedback about the consequences of behavior. Participants learn quickly that their
weight change reflects their adherence to their eating and
activity goals. Since weight loss (the reward) usually
slows over time, other strategies are used to reward positive behavior change. For example, behavior therapists
provide praise (a form of reward) to participants for
weight loss and help them schedule rewards for desired
behaviors (e.g., purchasing a new book or DVD, if the
participant meets her activity goal for the week). It is
important that the reward is received only if the participant successfully achieves her goal. The reward will not
be motivating if its receipt is not contingent on this
success.
A challenge in the treatment of obesity is that the
reinforcing value of successful weight loss is not always
immediately apparent, whereas behaviors that hinder
weight control efforts (e.g., consuming high-calorie
foods, engaging in sedentary activity) can be rewarding
in the short term (12). An important goal of behavior
therapy is to help patients increase the likelihood of
immediate reinforcement for engaging in healthy behaviors (e.g., providing a feeling of success after adhering to
a meal plan for the week). Teaching patients to focus on
the outcomes of their behaviors may be beneficial for
long-term weight control. In a pilot study, Sbrocco and
colleagues (13) randomized overweight individuals to a
traditional behavioral weight loss program or a “behavioral choice” treatment in which participants were
taught to recognize the consequences of their food and
activity choices (e.g., feeling guilty after eating a highcalorie food) and modify their thinking or behavior to
maximize positive outcomes. Although there were no
differences between groups in weight loss at the end
of treatment, participants in the behavioral choice
treatment continued to lose weight following treatment
whereas those in the traditional behavioral program
began to regain weight. As a result, participants in
the behavioral choice treatment had significantly
better weight loss maintenance 6 and 12 months
post-treatment.
Functional analysis, the examination of antecedent
events and consequences of problem behaviors, is
another tool used in behavioral treatment. Functional
analysis helps identify events (e.g., items, places, people)
associated with unhealthy eating and activity behaviors.
Such analysis helps participants recognize how problem
behaviors are often triggered through a series of events
that are linked together in a chain. An examination of
the links in the behavioral chain can help identify opportunities for intervention (see Figure 15-1).
Structure of treatment
Behavioral treatment is typically delivered in groups of
10–15 individuals in a closed group format (all participants begin the treatment program at the same time) for
60–90 minutes per session. The group format provides
valuable social support; participants help each other
identify and develop strategies for overcoming barriers
to their eating and activity goals. Group treatment
appears to result in larger weight losses than individual
treatment. A randomized controlled trial found that
participants in group treatment lost significantly more
weight than those assigned to individual treatment, even
among those who preferred to receive individual care
(14). Group sessions are initially held weekly during the
weight loss phase (16–26 weeks) and are followed by biweekly meetings that focus on the maintenance of weight
loss.
Treatment sessions typically begin with the clinician
privately measuring the weight of each participant.
During this weigh-in, the participant is told how much
his weight changed since the previous week, as well as
the total amount of weight change since beginning treatment. The clinician takes a moment to offer praise for
successful weight loss (or weight loss maintenance) and
responds supportively to participants who are disappointed with their weight change. When the group
meeting begins, the clinician asks each participant to
provide a report of her homework assignment and her
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256 Textbook of Obesity
1
Overslept;
assigned rush
project
2
Skipped
breakfast, lunc
h
and breaks
3
Worked
late
7
Ate chips
while
watching TV
Went to kitchen
got bag of
chips
9
Ate rapidly
until full
Left work tired,
stressed,
and hungry
5
6
8
4
Changed to
lounging
clothes
Drove
straight
home
10
Felt guilty
like a
failure
11
Restraint
weakened
further
12
More eating
and no
exercise
Figure 15-1 Sample Behavior Chain
A behavior chain illustrates how a series of events can become linked together to affect eating and activity behaviors. The behavior
chain helps identify where the individual can intervene in the future to prevent unwanted eating and inactivity. Thus, the individual
might plan to get additional sleep and prepare meals the night before in case he oversleeps. Figure reprinted from Brownell (15).
success in meeting calorie and activity goals. Typically,
participants will report the average number of calories
they consumed in the previous week and the total
minutes of physical activity they completed in the previous week. During this review, participants help each
other generate solutions for addressing barriers to eating
and activity goals. The remainder of the session is
devoted to the presentation and discussion of new material designed to enhance participants’ weight management skills, such as responding to cues for eating and
inactivity, finding time to exercise, making healthy
choices on weekends and holidays, and modifying
recipes. Time is reserved at the end of each session to
assign homework and review goals for the upcoming
week.
Components of behavioral treatment
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Behavioral treatment is delivered as a package that is
comprised of multiple components designed to facilitate
changes to eating and activity habits. These procedures
have been described in detailed treatment manuals,
such as the LEARN Program for Weight Management
(15) and the Diabetes Prevention Program’s Lifestyle
Change Program (16). The present chapter describes
self-monitoring, stimulus control, problem-solving, cognitive restructuring, and relapse prevention. Additional
research is needed to identify the most effective components of treatment.
Self-monitoring of eating, physical activity,
and weight
Self-monitoring is the cornerstone and perhaps the
most important component of behavioral treatment for
obesity (15, 17–18). Obese individuals have been shown
to underestimate their food intake and over-report their
physical activity by as much as 50% (19). Therefore,
participants are taught to keep records of their food
intake, physical activity, and weight throughout treatment. Participants record detailed information about the
types, amounts, and calorie content of the foods and
beverages they consume, as well as the duration and
form of exercise they complete (see Figure 15-2 for an
example). Participants receive training in reading food
labels and using measuring utensils (e.g., scales, cups,
spoons) in order to enhance the accuracy of their food
records.
As treatment progresses, additional contextual information (e.g., location of eating, hunger ratings, feelings)
can be added to the food record in order to identify trig-
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Behavioral approaches 257
Monitoring Record
Day of Week Monday
Time
Date 7/26
Calories
Food: Amount & Description
Cheerios, 1 cup
100
Skim milk, ½ cup
45
1 small apple
Orange juice, 6 fl. oz.
55
10:00 AM
1 medium banana
105
1:00 PM
Turkey sandwich
7:00 AM
2 oz. turkey
84
60
1 tbsp light mayo
50
2 slices whole wheat bread
140
1 slice tomato
5
1 light yogurt
100
1 chocolate chip cookie
50
3:30 PM
1 oz. pretzels
108
6:30 PM
3 oz. chicken breast, roasted
1 small baked potato with 1 pat of
butter
½ cup chopped broccoli
140
Daily Total
164
27
1233
Type of Physical Activity
Minutes
Brisk walking
25
TOTAL MINUTES DAILY PHYSICAL ACTIVITY
25
Figure 15-2 Sample Food and Exercise Monitoring Record
Self-monitoring is the cornerstone of behavioral treatment for
obesity. Participants begin by recording the times, amounts, and
calories of foods consumed and the physical activity they engaged
in. The extra column can be used to monitor additional contextual
information (e.g., places, feelings) throughout treatment in order
to help identify problematic behavior patterns that can be targeted for intervention.
Several studies have found that individuals who regularly keep food records lose significantly more weight
than those who record inconsistently (20–23). For
example, Berkowitz and colleagues (20) compared the
weight losses achieved by obese adolescents who most
consistently completed self-monitoring records to those
who were less adherent with their food recording. They
found that participants who self-monitored more frequently achieved a greater reduction in body mass index
(BMI) than patients who self-monitored less frequently
(11.5% vs. 6.3%, respectively) during the first six months
of treatment (20).
Self-monitoring likely reduces the tendency to underestimate food intake by increasing awareness of eating
behaviors. It prevents a participant from forgetting
about the Hershey Kisses she ate from a co-worker’s
candy dish or the “tasting” she did while cooking dinner
for her family. Participants often report that it keeps
them “accountable.” Food records may be especially beneficial during periods of high risk for weight gain, such
as holidays (24–25).
Self-monitoring of body weight has also been shown
to be associated with successful weight control (26–28).
Participants in behavior therapy are instructed to weigh
themselves at home in addition to their weekly weigh-in
with their therapist. Their weights can be tracked visually using weight graphs, which provide participants
with a visual representation of their progress throughout
the program. A study of successful weight loss maintainers found that over three-quarters of the sample weighed
themselves at least once per week (26). Furthermore,
participants who decreased their self-weighing frequency
over a one-year period gained significantly more weight
than those whose self-weighing frequency increased or
stayed the same (26). Self-monitoring of weight may
help participants catch small weight gains and make the
necessary behavior changes to prevent additional weight
gain.
Stimulus control
gers of problematic eating. An individual, for example,
might notice that he tends to overeat in the evenings
when he does not have an afternoon snack. Another may
realize that she consumes more calories at lunch on
workdays if she eats at a fast-food restaurant rather than
bringing lunch from home. Records can reveal social
circumstances or even people that trigger problematic
eating or other circumstances that undermine efforts to
be more physically active. Once problem areas have been
identified, a plan for overcoming the obstacle can be
developed.
There is considerable empirical support for the use of
self-monitoring in behavioral treatment for obesity.
Stimulus control techniques use the principles of classical and operant conditioning to help participants make
their environments more conducive to healthy eating
and exercise. As described previously, an event can
become a cue to eat when it is repeatedly paired with
eating. For example, walking into the kitchen often elicits
a desire to eat because this room is strongly associated
with food. People rarely experience a food craving when
in the attic because of the absence of food cues in this
area. Several studies provide evidence of environmental
influences (i.e., proximity and visibility of food) on
eating behavior. One study, for example, found that participants consumed more chocolate when the chocolates
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258 Textbook of Obesity
were placed on their desks (as opposed to 2 meters away)
or when they were placed in clear (rather than opaque)
containers (29). Another experiment reported that participants ate more chicken wings in a restaurant when
the chicken wing bones were cleared as they were eating
(removing a visual cue of how much had been consumed) in comparison to those whose tables were not
cleared (i.e., chicken wing bones remained visible on the
table) (30).
Behavior therapy incorporates several strategies in
order to limit exposure to cues that prompt overeating.
Participants are taught to store foods out of sight, limit
the places that they eat to the kitchen or dining room,
and refrain from engaging in other activities while eating
(such as reading or watching television). These strategies
weaken the strength of these cues by disconnecting them
from eating. Stimulus control strategies are also used to
create positive cues for healthy eating and physical activity. A participant might, for example, place a fruit basket
on the kitchen counter in order to encourage consumption of a healthy snack. Another might move his treadmill from the basement to a more visible and possibly
more pleasant place in the house to remind him to exercise. Stimulus control aims to decrease negative cues
while increasing positive ones (15). One novel study
found that encouraging patients to use an online grocery
shopping and delivery service rather than do conventional grocery shopping reduced the number of high-fat
foods in the house (31). This effect likely occurred
because participants’ exposure to tempting food cues in
the grocery store was reduced. Future studies are needed
to evaluate the long-term impact of interventions
designed to improve stimulus control in weight management programs.
Problem-solving
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Behavioral approaches teach patients that planning
meals and activity schedules is an essential tool for successful weight control. Even the best “planner,” however,
will encounter barriers. Therefore, problem-solving
skills are taught as part of the behavioral treatment
package. Participants learn to solve problems using a
five-step process (32). The first step is to identify the
problem in detail. It can be useful to create a behavior
chain (see Figure 15-1) illustrating the events that led to
the problem behavior and identify which links in the
chain to target. Once the problem is clearly specified, the
second step involves brainstorming potential solutions
to the problem. Participants are encouraged to be as
creative as possible in generating ideas. In the third step,
participants consider the pros and cons of each option.
Fourth, participants choose a solution and develop a
plan for implementing it. The final step involves evaluat-
ing the effectiveness of the chosen solution. If the
problem was not successfully solved, the process can be
repeated. Research suggests that increasing problemsolving skills has been associated with improved weight
loss (33) and weight loss maintenance (34).
Cognitive restructuring
Behavioral treatment also targets negative thinking that
can create obstacles to successful weight control.
According to cognitive theories of behavior change, a
person’s thoughts determine how he will respond to
different events. For example, catastrophic and dich­
otomous thinking often occurs among individuals
attempting to lose weight and can lead them to abandon
their weight control efforts. For instance, a person may
overeat and have the thought, “I’ve blown my diet, I
should just give up,” and consequently continue overeating. In behavioral therapy, participants are taught to
monitor their thoughts and replace cognitive distortions
with rational responses. For instance, a participant may
learn to respond to overeating by having the thought, “I
know that was not the best choice I could have made,
but I am going to stick with my plan for healthy eating
for the rest of the day.” Rational responses such as “Just
because I ate an extra 300 calories for lunch does not
mean I will not be able to lose weight this week” are more
likely to elicit positive eating and activity habits. Cognitive
restructuring is helpful in teaching patients to view a
setback as a temporary lapse.
Relapse prevention
Behavioral treatment for obesity includes training in
relapse prevention based on Marlatt and Gordon’s
work in addictions (35) in order to help prepare a participant to maintain their weight loss in the long term.
Participants are taught to anticipate and develop strategies for dealing with high-risk situations (e.g., vacations,
periods of stress at work). They also learn to plan for
how they will respond to “slips” from their new eating
and activity habits, which are viewed as an expected part
of the weight management process. Relapse prevention
strategies turn slips into learning opportunities that
enable participants to navigate future situations more
successfully.
Dietary components of behavioral treatment
Standard dietary treatment
Create an energy or calorie deficit
Standard behavioral treatment typically recommends an
intake of 1,200–1,800 calories per day to induce weight
loss. Weight may be used to determine a calorie goal,
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Behavioral approaches 259
with those weighing above 113.5 kg consuming 1,500–
1,800 kcal/day and those less than 113.5 kg consuming
1,200–1,500 kcal/day. Given variations in energy needs
based on height, weight, sex, age, customary activity
level, and nonspecific individual differences, it is difficult
to determine exactly what level of calorie intake will
produce the desired weight loss of 0.5–1 kg per week.
This is usually approximated by creating a deficit of 500
calories per day which can theoretically produce 0.5 kg
of fat loss per week, but for many people, such a large
deficit may feel like deprivation. With trial and error, the
participant and treatment provider can determine an
exact calorie goal within this range. Behavioral strategies
such as self-monitoring of food intake and stimulus
control are used to help participants limit food intake
and meet calorie goals.
Design a nutritionally balanced diet
A nutritionally balanced diet is emphasized in behavioral treatment and based on the Food Guide Pyramid.
Federal guidelines suggest limiting dietary fat to less
than 30% of calories, with 50% of total calories
com­ing from carbohydrates and 20% from protein (36).
Behavior therapy encourages controlling portion sizes
and limiting calorie intake by consistently weighing and
measuring foods. Table 15-2 presents a summary of
dietary recommendations used in standard behavioral
treatment.
Aside from the balanced deficit diet frequently used
in behavior therapy for obesity, there are several alternative nutritional components that may be used to help
meet energy deficit goals. Some of these approaches are
designed to produce greater initial weight losses, while
others focus on facilitating greater long-term adherence
to calorie goals (37–39). Examples of these approaches
include very-low-calorie diets, meal replacements,
portion-controlled diets, low-carbohydrate diets, and
low energy-density diets. Each of these is discussed
briefly in this section.
Very-low-calorie diets (VLCDs)
VLCDs were widely used in weight loss treatment programs in the 1980s and early 1990s (40) and are occasionally used in treatment today. They are defined by the
National Heart Lung and Blood Institute as diets providing less than 800 kcal/day (41). This definition, however,
fails to take into account individual dietary needs and
deficits, such as the impact that sex, level of obesity, and
age might have on daily energy expenditure and necessary energy deficit. Investigators therefore suggest defining VLCDs as any diet that provides ≤50% of an
individual’s predicted resting energy needs (42–43).
VLCDs are designed to produce rapid weight loss while
maintaining lean body mass, especially muscle, organ
tissues, and bone. They typically consist of high-protein
shakes that are consumed 4–5 times per day, in addition
to multivitamin and mineral supplements (44). Popular
commercial versions of VLCDs are produced by Optifast
and Health Management Resources. VLCDs are considered safe and effective when used by appropriately
selected obese individuals. Contraindications can
include a diagnosis of bulimia nervosa, major depressive
Table 15-2 Summary of Dietary Recommendations for Weight Loss
Element
Recommendation
Comments
Energy (kcal)
Reduce intake by 500–1,000 kcal/day
Should lead to sustained weight loss of 0.5–1 kg/wk
Fat
20–30% of total energy intake
Reducing dietary fat without restricting energy is not sufficient for
weight loss; include foods that are reduced in fat and energy density
Carbohydrates
≥55% of total energy
Emphasize complex carbohydrates from whole grains, vegetables,
and fruit
Protein
15% of total energy
Include low-fat varieties of beef and pork, roasted poultry without
skin and fish
Alcohol
Limit to 1 drink/day for women; 2
drinks/day for men
Consume with meals
Fiber
20–30 g/d
Choose whole grains, fiber-rich breakfast cereals, whole fruits,
vegetables, and legumes
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Table reprinted from ref. (134).
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260 Textbook of Obesity
disorder, substance abuse disorders, or any acute psychiatric illness that would impair dietary adherence. Patients
need to be examined by a physician regularly (e.g., twice
a week) during weight loss (45). Side effects can include
hair loss, fatigue, dizziness, and increased risk of gallstones. Unsupervised use of VLCDs can result in serious
complications, particularly when used for long periods
without close medical supervision.
Research suggests that VLCDs produce rapid and significant weight losses of 20–25% of initial body weight
during 12–16 weeks of treatment (42). These weight
losses, however, are not well maintained. Even when
combined with behavior therapy, patients typically
regain 35–50% of lost weight in the year following treatment, and all weight lost is often regained within 3–5
years of treatment (44). Tsai and Wadden (42) conducted
a meta-analysis of six studies that conducted randomized
comparisons of conventional low-calorie diets to VLCDs
and had a follow-up assessment of at least one year after
maximum weight loss. The VLCDs in the six studies
produced greater short-term weight losses but comparable long-term losses and similar rates in attrition. While
the rapid weight losses of VLCDs are appealing to some
patients in the short term, the lack of effective weight
loss maintenance strategies at the end of active weight
loss treatment is concerning, and there are no adequate
data to suggest that the rapid weight losses experienced
in the first 12 months of treatment result in greater
health improvements than with standard low-calorie
diets (44).
Meal replacements
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One promising alternative to a VLCD is the use of a meal
replacement diet. Originally developed as over-thecounter modifications of VLCDs, meal replacements are
defined as functional foods in the form of drinks or
bars as a meal replacement (46). The best-known meal
replacement is Slim-Fast. Behavioral therapy programs
that use meal replacements generally recommend that
patients replace two meals and one or two snacks each
day with a meal replacement. The remaining meal is
comprised of self-selected conventional foods, such as a
dinner of chicken, rice, and a vegetable. A meal replacement diet contains more calories and therefore a more
complete micronutrient profile than a VLCD. Meal
replacements are considered safe when used as directed
and can be readily incorporated into behavioral treatment. By reducing the variety of foods in the diet and
increasing dietary structure, meal replacements facilitate
adherence to the daily calorie goal. Patients can also
learn to use meal replacements in situations in which
they would otherwise engage in disinhibited eating or
make unhealthy food choices. For example, patients can
be encouraged to keep meal replacements in their car for
situations in which they might otherwise eat at a fastfood restaurant (e.g., running late to a meeting). Meal
replacements are very convenient, require little preparation, and allow dieters to avoid contact with problem
foods (42). Relative to some other types of food (e.g.,
fast-food meals, frozen meals) they are also inexpensive.
Importantly, meal replacements eliminate the need to
make decisions about which and how much food to eat.
Thus, they might facilitate a more accurate estimation of
calorie intake, which, as noted previously, is a challenge
for many obese individuals (19).
There is strong evidence that the use of meal replacement facilitates weight control (47). A meta-analysis of
seven randomized trials found that patients who used
meal replacements lost an average of 4 kg more after
six months (and 3.8 kg more after 12 months) than
those who followed a conventional weight loss diet
(48). Meal replacements might be especially useful for
promoting long-term weight control. Flechtner-Mors
and colleagues (49) found that patients who continued
to substitute one meal and one snack each day with
meal placements after initial weight loss maintained a
weight loss of 11% after 27 months and 8% after 51
months.
Some treatment providers or patients may be concerned that the use of meal replacements and other
highly structured diets may induce binge-eating or foster
poor eating habits (47). Research indicates that this is
not the case. Wadden and colleagues (50) conducted a
randomized controlled trial to examine the effects of
weight loss dieting on binge-eating among obese individuals without a prior history of eating disorders.
Patients were randomized to one of three conditions: 1)
a balanced deficit diet of 1,200–1,500 kcal/day, 2) a nondieting treatment (which discouraged caloric restriction), and 3) meal replacements. Patients in the meal
replacement condition were initially prescribed a completely liquid diet of 1,000 kcal/day for 14 weeks, after
which they gradually decreased their consumption of
meal replacements until they were consuming 1,200–
1,500 kcal/day of self-selected foods (similar to the
balanced deficit diet condition). After 65 weeks, no differences emerged between groups in binge-eating or
mood changes (50).
Additional concerns have been raised about whether
meal replacement diets provide adequate nutrition. In
order to assess this concern, Ashley and colleagues (51)
compared the nutrient intake of participants randomized to a conventional food or meal replacement
group. They found that patients in the meal replace­
ment condition had a higher intake of vitamins and
minerals than those who consumed a diet of conven-
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tional foods. Meal replacements are also safe to use
with those with type 2 diabetes and have not been found
to adversely affect glycemic control (47). While it is
unclear whether meal replacements are superior to
other dietary approaches that provide a similarly high
level of structure and portion control, it appears that
meal replacements are an appropriate nutritional
component to use as part of behavioral treatment for
obesity.
Portion-controlled diets
VLCDs and meal replacements are both designed to
address the challenges of a conventional food diet, which
requires the dieter to make food choices and estimate
portion sizes at every meal. Portion-controlled diets
offer another approach for addressing these challenges.
Structured, portion-controlled diets help avoid cues for
overeating by simplifying choices, reducing variety, limiting temptation, and eliminating the need for laborious
food preparation (52). They also address the common
problem of food intake underreporting (19), which can
occur when individuals underestimate portion sizes, fail
to recognize hidden sources of fat and/or sugar, or forget
some foods eaten.
Several studies have shown that portion-controlled
servings of conventional foods improve both the weight
loss phase and the maintenance of weight loss phase.
Jeffery and colleagues (53) found that participants who
were prescribed a diet of 1,000 kcal/day and provided
with five breakfasts and five dinners a week lost significantly more weight at 6, 12, and 18 months than participants who were prescribed the same number of calories
but consumed a diet of self-selected foods. A follow-up
study (54) compared weight losses among groups that
received standard behavioral treatment combined with
(a) no additional structure; (b) structured meal plans
and grocery lists; (c) meal plans with food provided at
reduced cost; or (d) meal plans with free food provision.
Although the calorie goals were equivalent across groups,
participants in the last three groups lost significantly
more weight after six months of treatment and maintained greater losses at an 18-month follow-up than did
those who received no additional structure, which suggests that structure alone, as provided by prepackaged,
portion-controlled meals, was enough to improve weight
control. Many other studies have demonstrated the benefits of using pre-packaged, portion-controlled meals,
including frozen-food entrées, for weight loss (4, 55–58).
As with meal replacements, pre-portioned items like
frozen entrées eliminate the need to weigh and measure
food and they save time planning and preparing meals
(44). When combined with behavior therapy, portioncontrolled meals make self-monitoring easier and reduce
the need to weigh and measure foods, potentially making
adherence to treatment goals easier.
Low-carbohydrate diets
Low-carbohydrate diets have been studied extensively in
recent years (59–64). These diets limit carbohydrate
intake to 50–100 g daily, without restrictions in dietary
fat or calories. The consumption of high-protein foods
has been shown to promote satiety (e.g., 65–69).
Furthermore, limiting intake of an entire class of
macronutrients—in this case, carbohydrates—might
also facilitate calorie restriction. Three randomized controlled trials have compared low-carbohydrate and lowfat diets: two found no weight loss differences between
groups at one year (60, 62), and one provided favorable
long-term support for a low-carbohydrate diet (64). In
the largest long-term randomized controlled trial (70)
conducted to date, four diets were compared. At two
years, weight loss was similar in groups that were assigned
to a diet with low- or high-protein, low- or high-fat, and
low- or high-carbohydrates. Taken together, these findings indicate that calorie intake, not macronutrient composition, determines long-term weight loss maintenance.
However, the amount or type of macronutrient (e.g.,
simple vs. complex carbohydrates or saturated versus
unsaturated fats) may have important health implications, particularly for conditions such as type 2 diabetes
or cardiovascular disease.
Low energy-density diets
Low energy-density diets present yet another option for
weight control. Energy density is defined as the amount
of calories in a given weight of food (kcal/g). The principal rationale for a low energy-density diet is that, for
the same amount of calories, a greater volume of food
can be consumed when the food is low in energy density
than when its energy density is high. Thus, a low energydensity diet allows people to eat a satisfying amount of
food while limiting energy intake (71). Low energydensity diets are also typically of high nutritional quality.
Data from the Continuing Survey of Food Intakes by
Individuals indicate that individuals who eat low energydensity diets, compared to those who eat high energydensity diets, consume fewer calories, a greater volume
of food, less fat, and more micronutrients, including
vitamins A, C, and B6, iron, calcium, and potassium (72).
Several randomized clinical trials support the effectiveness of energy density interventions. In one clinical
trial (73), the intervention group was instructed to
incorporate portions of fruits, vegetables, broth-based
soups, and other low energy-density foods into their diet
ad libitum, and to prepare and choose foods with less
fat. The comparison group was instructed to reduce their
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262 Textbook of Obesity
portion size of all foods and reduce their fat intake.
Weight loss in the intervention group was significantly
greater at six months than in the comparison group (9 kg
vs. 6.7 kg, respectively). In another study (74), obese
women were randomly assigned to a weight loss condition that emphasized reducing fat intake or one that
emphasized reducing fat and increasing intake of waterrich foods, especially fruits and vegetables. Participants
in the low-fat only group lost significantly less weight at
six months than participants in the combined group
(6.7 kg vs. 8.9 kg, respectively), but weight loss maintenance at 12 months was not significantly different
between groups (6.4 kg vs. 7.9 kg). Of note, participants
in the condition that emphasized water-rich food intake
reported significantly less hunger than those in the lowfat only group. A low energy-density diet could be an
excellent option for dieters who struggle with hunger.
This approach would let them eat more food while
potentially decreasing their food intake.
Physical activity components of
behavioral treatment
La
Physical activity is widely recognized as an essential
component of weight loss treatment. Participants in
behavioral treatment programs set specific goals for
physical activity and receive support for increasing and
then maintaining a high level of physical activity (75–
76). Engaging in physical activity without concurrent
caloric restriction is of limited benefit in inducing weight
loss (77). However, combining dietary restriction with
increased physical activity facilitates weight loss and
helps prevent weight regain (77). Physical activity
appears to influence the composition of weight loss so
that a higher proportion of the weight loss is loss of fat
and a smaller proportion is fat-free mass, which is metabolically desirable (78). This may help offset the reduction in resting metabolic rate that results from weight
loss (78). Engaging in physical activity during weight loss
might also facilitate dietary adherence and better prepare
participants for weight loss maintenance (78–79).
Physical activity appears to be a critical component of
successful weight loss maintenance (76, 80–81). A metaanalysis of 18 randomized weight loss trials found that
combined diet-plus-exercise interventions produced
greater long-term weight loss than interventions that
only included diet, particularly in interventions lasting
longer than one year (82). Members of the National
Weight Control Registry report maintaining their weight
losses by engaging in approximately one hour per day of
physical activity, through which they expend an average
of approximately 2,825 kcal per week (83). Other studies
have reported similar results: those who consistently
engage in physical activity following weight loss have a
higher likelihood of maintaining their weight losses (82,
84–85). Physical activity is also important in reducing
the risk for several chronic diseases and medical conditions that are especially prevalent in the obese (e.g.,
coronary heart disease, diabetes, hypertension). Other
benefits of physical activity include reduced stress,
increased emotional well-being, reduced depression
(and possibly therefore reduced emotional eating),
increased energy level, improved sleep, and improved
self-confidence (79). Emphasizing the role physical
activity has on these benefits is imperative when encouraging lifestyle modification.
Recommended amount of physical activity
The Centers for Disease Control and Intervention, the
American College of Sports Medicine, and the American
Heart Association recommend that healthy adults age
18–65 years engage in 150 minutes of exercise of moderate or greater intensity (between 60–80% maximum ageadjusted heart rate) each week (78). This level of activity
produces energy expenditure of approximately 1,000 kcal
per week. This recommendation is useful for preventing
weight gain in normal weight individuals, but greater
amounts are needed for weight loss and weight loss
maintenance. The American College of Sports Medicine
recommends 200–300 minutes per week of moderateintensity activity for long-term weight loss (85).
Additional research, reviewed next, suggests that the
amount of physical activity necessary for weight loss
maintenance may be even higher than that.
Jeffery and colleagues (84) compared an 18-month
behavioral weight loss treatment program combined
with two different levels of physical activity, equivalent
to either 2,500 or 1,000 kcal per week of energy expenditure. Participants assigned to complete the higher level
of physical activity (equivalent to approximately 75
minutes per day of brisk walking) experienced significantly greater initial weight losses and greater weight loss
maintenance at 18 months than those told to complete
a lower level of physical activity. However, most participants were unable to sustain this high level of physical
activity after 18 months, so group differences were no
longer apparent by 30 months (86). Of note, those participants who were able to sustain a high levels of physical activity (i.e., expending at least 2,500 kcal per week
with exercise) maintained significantly larger weight
losses at 30 months than those participants whose
engaged in a lower level of physical activity (12 kg vs.
0.8 kg). Jakicic and colleagues (87) found similar (nonexperimental) results among obese participants in a
behavioral treatment program: participants who were
exercising 200 minutes or more per week lost more
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Behavioral approaches 263
weight and had significantly greater weight loss maintenance at 18 months than did those who exercised less.
Other research indicates that 70–80 minutes per day of
moderate intensity activity is needed to prevent weight
regain in the year after weight loss (81).
The role of type of exercise
It should be noted that while the physical activity component of behavior therapy focuses primarily on cardiovascular activity (e.g., brisk walking) because of its
calorie-burning contribution to weight loss, musclestrengthening activities should be encouraged as well.
The Centers for Disease Control and Prevention recommend that adults engage in muscle-strengthening activity at least two days per week, working all the major
muscle groups (88). Mild-to-moderate resistance training is an effective method of improving muscular
strength and endurance, preventing and managing a
variety of chronic medical conditions, modifying coronary risk factors, and enhancing psychosocial well-being
(89). There is also some evidence that muscle strengthening can help preserve fat-free mass during weight loss
and that preservation of fat-free mass enhances maintenance of resting metabolic rate following return to
energy balance (90). Muscle-strengthening activities
should serve as a complement to, rather than a replacement for, the patient’s cardiovascular activity prescription (89).
Meeting physical activity goals
Facilitating changes in physical activity is notoriously
difficult. Fewer than one-third of adults in the US meet
the minimum recommended levels of moderate physical
activity, defined as at least 30 minutes per day (91–92).
Adults who do not meet recommended physical activity
goals commonly report that they face barriers such as
limited time, cost, lack of resources, childcare, fatigue,
and health problems (79).
To reinforce the importance of physical activity in
weight loss treatment, the principles of behavior therapy
are applied to increasing physical activity in much the
same way as dietary restriction. Behavior therapy encourages setting specific and measurable physical activity
goals each week, as well as daily self-monitoring of activity. Self-monitoring of physical activity can be completed
in the same log that is used to track dietary intake (see
Figure 15-2). Individuals are encouraged to monitor the
type of activity and the total minutes of activity completed each day. Physical activity goals are increased
slowly over the course of behavioral weight loss treatment. For example, an initial goal might be to walk at
least 10 minutes per day, four days per week (or a total
of 40 minutes per week). Each week, the targeted amount
of physical activity might increase by approximately 10
minutes, progressing over several months to an eventual
goal of 180–200 minutes of activity a week. Pedometers
can be used to track total steps taken each day. Behavioral
treatment participants are asked to record the total
number of steps each day on their daily monitoring
form. Participants work toward an eventual goal of at
least 10,000 steps per day (the equivalent of approximately 5 miles). Problem-solving also is used to identify
barriers to physical activity and formulate solutions to
those barriers. Lastly, stimulus control is encouraged. For
example, individuals might try leaving their sneakers by
the door as a reminder to go for a walk before they leave
for work in the morning or they might place a treadmill
in the living room as a cue to walk at home while watching television. Other ways to enhance compliance with
physical activity goals include providing psychoeducation regarding the importance of exercise, encouraging participants to seek social support (e.g., find a
walking partner or enlist a family member to provide
childcare), providing appropriate models of physical
activity that match skill levels and individual preferences,
and providing positive reinforcement for meeting physical activity goals.
Intermittent vs. continuous activity
As noted previously, lack of time is frequently cited as a
barrier to meeting physical activity goals. With recommended goals as high as 70–80 minutes per day, it is
understandable that this is a challenge. To address this,
investigators have examined whether physical activity
goals can be met by performing short bouts of activity
throughout the day rather than engaging in a single continuous bout. Research has demonstrated that intermittent and continuous activity of the same total duration
produce equivalent improvements in cardiovascular
health, weight, and fasting or postprandial lipemia (93).
For example, Jakicic and colleagues (87, 94) randomized
participants in behavioral weight loss treatment to follow
a routine of either multiple, short bouts of activity, completed in intervals of at least 10 minutes, for 40 minutes
per day, or 40 minutes of exercise completed in a single
bout each day. Multiple short bouts were as effective as
longer bouts in producing long-term weight losses and
improving cardiovascular fitness (see Figure 15-3) (94).
These studies suggest that patients can choose between,
for example, 40 continuous minutes of brisk walking
daily, and four, 10-minute brisk walks throughout the
day. This is beneficial for those who are unable to set
aside a 30–60 minute block of time each day or are overwhelmed by the idea of having to do 30 minutes of
activity most days of the week. For such patients, encouraging short bouts of activity may increase compliance
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264 Textbook of Obesity
250
0
p = 0.08
Diet + Lifestyle Group
Long Bouts
(one 40-minute
session)
150
Short Bouts
(four 10-minute
session)
100
50
p = 0.07
Activity (min/wk)
–4
–6
–8
Weight loss (kg)
Figure 15-3 Effect of Long vs. Short Bouts of Exercise on Total
Amount of Activity and Weight Loss
Participants were given the same instruction on diet modification,
but were told to engage in either one 40-minute bout of exercise
or four 10-minute bouts of exercise throughout the day. Partici­
pants in each condition experienced similar patterns of total daily
activity and weight reduction, suggesting that several small bouts
of exercise are as effective as one long bout for producing weight
loss. Data reproduced from reference (94).
in treatment. Evidence also suggests that exercising
throughout the day may help prevent injuries by making
the intensity of activity occur in smaller bursts rather
than one long burst (79). It is generally agreed that the
short bouts of activity should last at least 10 minutes in
order to gain cardiovascular benefits of exercise (87, 95).
Programmed vs. lifestyle activity
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–2
Change in Weight, kg
200
0
Diet + Aerobic Group
Some adults report that they dislike structured exercise
and thus feel that they will never be able to maintain a
consistent exercise program. Fortunately, many types of
activity can produce weight control and health benefits.
Individuals participating in a behavioral treatment
program for obesity can increase their energy expenditure in two ways: programmed or lifestyle activity (4).
Programmed activity refers to structured exercise that is
completed in a discrete period of time (e.g., 30 minutes)
at relatively high intensity. Examples include step aerobics, brisk walking, jogging, swimming, and cycling.
Lifestyle activity refers to bouts of movement throughout the day that increases energy expenditure without
concern for the intensity or duration of the activity.
Examples of lifestyle activity include taking the stairs
instead of the elevator, parking farther away from store
entrances, and walking to a neighbor’s house instead of
driving.
Research suggests that structured exercise and lifestyle
activity offer similar health benefits (80, 95–96). For
example, Andersen and colleagues (80) randomized participants in a behavioral weight loss trial to either structured aerobic exercise (for up to 60 consecutive minutes,
–10
0
4
8
12
16
68
Week
Figure 15-4 Weight Maintenance Can Be Achieved with Either
Programmed or Lifestyle Activity
Participants were randomly assigned to an aerobic exercise condition, wherein they participated thrice weekly in a step aerobics
class, or to a lifestyle program, wherein they were advised to
integrate 30 minutes of moderate-intensity activity into their daily
routine. Participants in each group experienced a significant
reduction in weight, indicating that programs promoting lifestyle
changes may be as effective as programs involving intense exercise. Figure reprinted from reference (80).
three times per week) or lifestyle activity (30 minutes per
day, most days of the week). The types of lifestyle activity
encouraged included walking instead of driving short
distances and taking the stairs as opposed to the elevator.
Participants were also encouraged to self-monitor their
daily activity using accelerometers. The authors found
that the diet plus lifestyle activity intervention was as
effective as the diet plus structured activity intervention
in producing desired changes in weight (see Figure 15-4),
systolic blood pressure, and serum lipid and lipoprotein
levels. Additional research has demonstrated that a lifestyle approach to physical activity was as effective as
structured exercise in improving cardiovascular fitness
and body composition among particular groups of
people, including previously sedentary people, those
who were unable to engage in vigorous physical activity,
or those who reported that they could not find the time
for structured exercise (97). Some participants in behavioral treatment report that lifestyle activity is more easily
integrated into their daily routine and thus has the
potential to be more readily maintained over the long
term than structured exercise.
Additional methods of promoting physical activity
Research has explored the potential of on-site and homebased activity to promote adherence to physical activity
goals. When on-site supervised activity was compared to
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home-based activity as part of a behavioral weight loss
program, no differences in total number of minutes each
week or weight loss were observed during the first six
months of treatment (98). By 15 months, however, those
who were prescribed the home-based activity reported
more total minutes of physical activity and had significantly better weight loss maintenance than those participating in on-site treatment. Other studies have reported
similar findings, suggesting that on-site supervised activity does not produce greater adherence or weight loss
and in fact appears to have the opposite effect over the
long term (98–99). Home-based activity provides people
with flexibility in determining when to exercise and
addresses barriers such as travel, cost, time, and
self-consciousness.
Self-efficacy also appears important for adherence to
physical activity goals. Self-efficacy is a component of
social cognitive theory and is defined as an individual’s
perceived confidence in his ability to meet certain goals
and perform certain behaviors (100). Individuals who
have high self-efficacy with regard to physical activity
believe that they will be able to be physically active,
believe that they will successfully meet their activity
goals, and are confident that their activity efforts will pay
in the long run. Gallagher and colleagues (101) found
that individuals in a weight loss program who reported
higher levels of physical activity self-efficacy lost a significantly greater amount of weight at six months than
those who reported lower levels. They also, not surprisingly, reported adhering to higher levels of physical
activity.
Targeting improvements in self-efficacy as part of
the behavioral treatment program may therefore help
promote compliance to activity goals (101). A therapist
might target self-efficacy by emphasizing small goals at
the beginning of treatment, as well as encouraging participants to take note of positive consequences of physical activity (e.g., less shortness of breath when climbing
the stairs, less fatigue), and by providing positive feedback to them (52, 102). Other methods that have been
used successfully to help promote maintenance of physical activity include occasional mailings and periodic
phone calls to support and encourage sustained levels
once treatment ends (103). Additionally, the use of social
support (e.g., walking groups) has been found to help
promote adherence to activity goals, as have pedometerbased walking programs (i.e., counting the number of
steps taken vs. tracking time spent walking) (101, 104).
Physical activity in ethnic minorities and
those of lower SES
African American women and Hispanic adults are less
physically active than Caucasian adults. In addition,
adults with higher levels of education and income engage
in more physical activity than those with lower levels of
education and income (92). There are several factors that
could contribute to disparities in physical activity.
Minority and low-income neighborhoods have fewer
recreational facilities than neighborhoods that are primarily white or high-income (105). In many minority or
low-income neighborhoods, most options for engaging
in physical activity require a fee to participate (e.g., gym
facilities, pools, pilates/yoga studios) (105). Resources in
free parks in lower-income areas are typically sportsrelated (e.g., basketball courts, baseball fields) and may
not meet the needs of most overweight or obese adults.
The quality and safety of the resources available may also
be suboptimal and they may be in unsafe areas. Other
environmental barriers include lack of sidewalks, high
neighborhood crime rates, fear of injury, care-giving
responsibilities, lack of social support for exercising, lack
of space in the home, and lack of facilities at work (103,
106). More research is needed to determine the best
methods for addressing barriers to physical activity for
ethnic minorities and the economically disadvantaged.
The little research that has been done suggests that
promising strategies include emphasizing health benefits
of activity, including stress reduction; encouraging
engagement in practical and convenient forms of physical activity, such as walking, and emphasizing clear physical activity goals (106–107).
African American women also report that maintenance of their hairstyle is a significant barrier to engaging in moderate or vigorous physical activity (108, 109).
Physical activity that makes African American women
perspire and gets their hair wet makes maintenance of
their hairstyle difficult. Most of these women report that
they have their hair styled every two weeks and that more
frequent appointments would be too time-consuming or
costly (109). Therefore, when working with African
American participants who have this concern, walking
should be emphasized as an appropriate physical activity
that can be completed in 10-minute bouts throughout
the day to accumulate the recommended minutes per
week (109).
Improving weight loss maintenance
As noted in the first section of this chapter, weight loss
maintenance is the primary challenge of behavioral
treatment. One of the most promising ways of improving long-term outcomes of behavioral treatment is to
extend the length of treatment. A meta-analysis of 13
studies indicated that having continued on-site contact
with lifestyle modification treatment providers after
initial weight loss improved weight loss maintenance
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(110). For example, Perri and colleagues (111) found
that individuals who attended every-other-week group
maintenance sessions for the year after weight reduction
maintained 13 kg of their 13.2 kg end-of-treatment
weight loss, whereas those who did not maintained only
5.7 kg of a 10.8 kg loss. Maintenance sessions seem to
provide many patients with the support and motivation
they need to continue to practice weight control behaviors, such as keeping food records and exercising regularly (2).
Investigators also have examined the Internet and telephone as methods of facilitating extended contact
with the treatment team. These interventions are also
important to explore because of their potential to reach
large numbers of participants and to improve costeffectiveness. More than a dozen randomized controlled
trials have examined use of the Internet to deliver lifestyle modification to obese adults (112). Short-term
studies of these programs typically found that they were
more effective than minimal treatment, but less effective
than face-to-face treatment (113–117). In general, effective technology-based programs tailored information
and feedback from therapists and provided structured
instruction in diet, physical activity, and behavioral
strategies (112). Preliminary evidence indicates that
feedback features, such as progress charts, and social
support features, such as Web chats with other participants, are among the most effective components of
Internet treatment (118).
Several studies have examined use of the Internet specifically for weight loss maintenance, with mixed results.
In each of the studies reviewed here, participants were
randomly assigned to a weight maintenance intervention after initial weight loss, which was typically 7–10 kg.
In two such studies, face-to-face treatment was more
effective for weight loss maintenance than Internet treatment, consistent with many results in the weight loss
literature. Harvey-Berino and colleagues (119) compared the effectiveness of 12-month maintenance programs delivered over the Internet or face-to-face (with
minimal or frequent contact). At the end of treatment,
sustained weight loss was poorer in the Internet condition than in the minimal and frequent contact face-toface conditions (5.7 kg, 10.4 kg, and 10.4 kg, respectively).
Svetkey and colleagues (120) compared three interventions: unlimited access to an interactive technologybased intervention, monthly personal contact, or selfdirected treatment. After 30 months of weight loss
maintenance treatment, weight regain in the personalcontact condition (4 kg) was significantly lower than in
the interactive technology-based condition (5.2 kg) and
the self-directed group (5.5 kg). Regain in the latter two
conditions was not significantly different.
In two other studies, Internet and face-to-face weight
loss maintenance treatment were found to be equally
effective. Harvey-Berino and colleagues (121) conducted
another comparison of a 12-month program delivered
over the Internet or face-to-face (with minimal or frequent contact). Sustained weight loss after one year
of maintenance treatment did not significantly differ
between groups (7.6 kg, 5.5 kg, and 5.1 kg, for the
Internet, minimal face-to-face contact, and frequent
face-to-face contact conditions, respectively). Finally,
Wing and colleagues (28) compared a monthly Internet
treatment with monthly face-to-face treatment and a
quarterly newsletter control condition. After 18 months
of maintenance intervention, the amount of weight gain
was not significantly different in the Internet (4.7 kg)
and face-to-face (2.5 kg) conditions. Weight gain was
significantly less in both these conditions than in the
control group (4.9 kg).
It also appears that frequent telephone contacts can
help maintain weight loss in adults. Perri and colleagues
(122) demonstrated that therapist contact by phone or
mail significantly improved weight maintenance, compared with no further intervention. Wing and colleagues
(123) demonstrated that after an initial six-month
behavioral weight control program, the addition of
weekly 15-minute phone calls were successful in preventing weight regain during a 12-month follow-up. In
summary, behavioral treatment should continue to be
delivered over the long term to continue teaching weight
loss maintenance skills, and several forms of technology
have promise in supporting long-term treatment contact.
Contributors to weight regain vs. weight
loss maintenance
At the most basic level, it appears that individuals who
can sustain reductions in calorie intake and engage in a
high level of physical activity are most successful at
weight loss maintenance. In general, participants report
that their adherence to behavioral treatment recommendations diminishes over time, and those who report
adhering most closely to treatment recommendations
demonstrate greater weight losses than those with poorer
adherence (59, 124).
A number of literature reviews have attempted to
examine within-group predictors or mediators of successful weight control among individuals seeking treatment. One review of research found that participants
who reported having few previous attempts at weight
loss had better weight loss or weight loss maintenance
than those who reported more previous attempts at
dieting (125). That review also found that an autonomous, self-motivated cognitive style was a strong
prospective predictor of successful weight loss (125).
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Table 15-3 Factors Associated with Weight Loss Maintenance
and Weight Regain after Intentional Weight Loss
Weight maintenance
Weight regain
An achieved weight loss
goal
Attribution of obesity to
medical factors
More initial weight loss
Perceiving barriers for weight
loss behaviors
Physically active lifestyle
History of weight cycling
Regular meal rhythm
Sedentary lifestyle
Breakfast eating
Disinhibited eating
Less dietary fat, more
healthful foods
More hunger
Reduced frequency of
snacks
Binge-eating
Flexible control over eating
Eating in response to negative
emotions and stress
Self-monitoring
Psychosocial stressors
Coping capacity
Lack of social support
Capacity to handle cravings
More passive reactions to
problems
Self-efficacy
Poor coping strategies
Autonomy
Lack of self-confidence
“Healthy narcissism”
Psychopathology
Motivation for weight loss:
more confidence
Motivation for weight loss:
medical reasons, other persons
Stability in life
Dichotomous thinking
Capacity for close relating
Table reprinted from ref (126).
Experimental research should examine whether treatment that specifically promotes this cognitive style can
improve outcomes. Another literature review identified
several traits and behaviors that were associated with
weight loss maintenance vs. weight regain (126). As
shown in Table 15-3, most of the factors associated with
success are targeted in behavioral treatment programs.
They include self-monitoring, physical activity, following a regular pattern of eating, and developing the capacity to respond to cravings and stress.
Several recent studies also yielded important findings
that add to this literature on factors associated with
weight control success. For example, Wadden and colleagues examined predictors of one-year weight loss for
participants in the Look AHEAD program (127). In this
program, 2,500 overweight or obese adults with type 2
diabetes received behavioral treatment. Participants who
attended more treatment sessions had better weight loss.
Consistent with evidence reviewed in an earlier section
of this chapter, the participants who engaged in the
most physical activity during treatment also had
the greatest weight losses at one year. Participants in the
highest quartile of physical activity lost 11.9% of initial
weight, compared with 4.4% for those in the lowest
quartile. Several demographic differences also were
found. Men lost significantly more weight than women,
although the size of this difference was small. The oldest
participants (aged 65–74 years) lost significantly more
weight than those aged 55–64 years or 45–54 years.
The differences in weight loss by sex and age can probably be attributed to difference in treatment adherence:
men and older adults had the best rates of treatment
attendance, the highest amounts of physical activity, and
the greatest consumption of meal replacements, which
were part of the program’s diet. Non-Hispanic White
participants lost more weight than African American or
Hispanic participants. This difference in outcomes by
race did not appear to be due to differences in treatment
compliance, and may be due to biological factors,
such as differences between groups in resting energy
expenditure.
Additional evidence about the importance of physical
activity as a predictor of success was provided by Brock
and colleagues (128). This study enrolled women who
completed a weight loss program and reached a BMI in
the normal weight range. Weight change was measured
for one year after completing the weight loss program.
On average, participants regained 5.5 kg during that
time. The authors found that perceived exertion during
a submaximal aerobic exercise task was predictive of
weight gain, such that those with highest ratings of exertion at the end of the weight loss period gained the most
weight in the following year. A physiological measure of
exertion was not predictive of weight regain, suggesting
that it was the perception of exercise difficulty that was
critical, not the actual level of exertion. This finding suggests that participants who have an aversion to physical
activity are likely to engage in it less frequently, and an
inadequate amount of physical activity may make it difficult for them to maintain their weight loss. Special
attention should be paid to such participants during
treatment to help them identify at least one form of
physical activity they enjoy.
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268 Textbook of Obesity
Another study examined how changes in particular
factors during treatment were associated with weight
loss maintenance at two years (129). Improvements in
flexible cognitive restraint, disinhibition, exercise selfefficacy, exercise intrinsic motivation, and body dissatisfaction during treatment predicted weight change at two
years. This indicates that programs are most successful
when they can help participants to adopt of a pattern of
flexible dietary restraint, decrease emotional eating,
develop intrinsic motivation for exercise, and develop
self-efficacy for exercise.
A final source of valuable information about successful weight loss maintenance comes from the National
Weight Control Registry, the database of individuals who
have maintained a weight loss of at least 13.6 kg for at
least one year (83). The National Weight Control Registry
is described in more detail in Chapter 22. Research on
these individuals provides a clear picture of the behaviors they engage in during weight loss maintenance.
Registry members have a high level of physical activity
(the equivalent of 1 hour per day of brisk walking),
consume a low-fat and low-calorie diet, monitor their
weight regularly, limit the variety of foods in their diet,
eat breakfast daily, and limit television watching (9, 130–
131). These activities are all targeted in behavioral treatment for obesity. Most recently, brain imaging research
has found that Registry members demonstrated greater
inhibitory control in response to food cues, as compared
to the responses of obese or normal-weight individuals
(132). Further research is necessary to determine if this
inhibitory control is a stable trait or if it was acquired. If
it is acquired, it suggests that treatment that promotes it
might improve outcomes.
Conclusion
Behavioral treatment is a gold standard of intervention
for obese adults. The weight loss produced with behavioral treatment is substantial enough to have significant
health benefits. The primary limitation of this approach
is that most participants regain weight when treatment
ends. Future research must identify novel approaches to
weight loss maintenance, including public policy and
environmental changes that can facilitate long-term
adherence to a restricted calorie diet and a high level of
physical activity.
Summary: Key Points
• Behavioral treatment of obesity typically includes monitoring eating, physical activity, and weight; stimulus control; problem-solving;
cognitive restructuring; and relapse prevention.
• During treatment, participants generally lose about 0.5 kg/week, much or all of which is regained in the majority within a year after
treatment stops. However a subset will maintain a loss of about 10% of initial body weight. This amount of loss is sufficient to lower
the risk of obesity-associated disease.
• Treatment sessions usually involve measuring of weight, with changes helping to direct the course of discussion during treatment,
which is often conducted in groups. Records of eating occasions and their context and the foods selected are also reviewed.
• Therapeutic approaches include functional analysis (the examination of antecedents and consequences of problem behaviors),
cognitive restructuring (changing negative thinking), and training for relapse prevention.
• Many different diets can be used during behavioral treatment including very-low-calorie diets, meal replacement diets, those
emphasizing portion control, or low-energy-density diets.
• Physical activity is an important part of weight loss during behavioral therapy, so increased energy expenditure is recommended. This
may be monitored using a pedometer, with the goal of gradually achieving 10,000 steps or more each week. Low-income and
minority groups face special barriers in participating in physical activities and these should be addressed in treatment programs.
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